Factor Xa Inhibitors versus warfarin in patients with morbid obesity and atrial fibrillation.

PURPOSE: Factor Xa Inhibitors have emerged as a first-line agent in the management of non-valvular atrial fibrillation (NVAF), but there is a need for additional data surrounding their use in the morbidly obese population. The purpose of this study was to evaluate whether Factor Xa Inhibitors are as safe and effective as warfarin for the treatment of NVAF in individuals with a BMI ≥ 40 kg/m2 and/or weight ≥ 120 kg. METHODS: This was a multi-center retrospective cohort study comparing the use of Factor Xa Inhibitors (apixaban and rivaroxaban) to warfarin for the management of NVAF in adult patients with a BMI ≥ 40 kg/m2 and/or weight ≥ 120 kg. The primary outcomes were stroke or systemic embolism and major bleeding within 12 months. RESULTS: A total of 3,156 patients were included in the final analysis; 1,396 in the warfarin group and 1760 in the Factor Xa Inhibitor group. The mean weight and BMI of the overall cohort was 134.1 kg and 44.7 kg/m2, respectively. There was no difference in stroke or systemic embolism (OR 1.21, 95% CI 0.78-1.85) or major bleeding (OR 0.99, 95% CI 0.65 - 1.53) with Factor Xa Inhibitors compared to warfarin after controlling for covariates. CONCLUSION: This analysis of real-world data suggests no difference in bleeding or thrombotic outcomes for severely obese patients with NVAF taking Factor Xa Inhibitors compared to warfarin. Overall, our study adds further data to support the use of Factor Xa Inhibitors as an alternative to warfarin in severely obese patients with NVAF.

Emerging Horizons in Heart Failure with Preserved Ejection Fraction: The Role of SGLT2 Inhibitors.

Heart failure with preserved ejection fraction (HFpEF) is a condition with increasing disease burden. Prevalence of HFpEF is increasing, reflecting an increasingly elderly and comorbid population, as well as reinforcing the need for more treatments for this disease. The pathophysiology of HFpEF is complex. Some inflammatory processes seen in HFpEF are shared with diabetes mellitus (DM) and there is an association seen between the two conditions. It is therefore no wonder that treatments for diabetes may have some effect on heart failure outcomes. Current treatment strategies in HFpEF are limited, with treatments focusing on symptom control rather than morbidity or mortality benefit. However, there are now promising results from the EMPEROR-Preserved study that show significantly reduced cardiovascular death or hospitalisation for heart failure (HHF) in patients taking empagliflozin, compared to those taking placebo. These results indicate a promising future for sodium-glucose co-transporter 2 (SGLT2) inhibitors in HFpEF. The ongoing DELIVER trial (investigating the use of dapagliflozin in HFpEF) is awaited but could provide further evidence of support for SGLT2 inhibitors in HFpEF. With hospital admissions for HFpEF increasing in the UK, the economic impact of treatments that reduce HHF is vast. The European Society of Cardiology (ESC) recently added SGLT2 inhibitors to their guidelines for treatment of heart failure with reduced ejection fraction (HFrEF) following DAPA-HF and EMPEROR-Reduced trials and we suggest that similar changes be made to guidelines to support the use of SGLT2 inhibitors in the management of HFpEF in upcoming months.

Message in a bottle: How evidence-based medicine and a programme change model improved asthma management in a low-income emergency department in Papua New Guinea.

OBJECTIVE: To improve asthma care in a complex, low resource, developing country setting. This observational study was carried out in a challenging low-income real-life setting in the ED at Modilon Hospital, Papua New Guinea. The only government hospital in Madang Province, with 258 beds, it provides medical care to a population of nearly 700 000 people of whom 40% live on less than US$1.25/day. METHODS: An asthma management analysis questionnaire followed by action research, with a four-step programme change model (exposure, adoption, implementation and practice), were used to develop and implement new department asthma guidelines. Staff perceptions were gathered via discussion groups and questionnaire. RESULTS: Asthma management initially involved frequent antibiotics, intravenous steroids, multiple short acting bronchodilators (oral, inhaled and nebulised) and limited oral steroids. No spacers, preventative inhaled steroid therapy or asthma action plans were used. On review after new guideline implementation staff felt antibiotic dispensing and concurrent use of multiple short acting oral bronchodilators decreased and spacer, preventer therapy and action plan use increased. CONCLUSION: This project highlights the difficulties experienced with change management, both in general and in a limited resource setting. Lack of data limits conclusions about asthma management improvement. However, positive trends were apparent and make this approach reasonable for those considering change management strategies in a similar setting.

Examining experiences of transition, instability and coping for young offenders in the community: A qualitative analysis.

This article explores experiences of transition, instability and coping using a qualitative approach with young offenders within a specialist forensic child and adolescent mental health service (CAMHS). Participants were four young people (aged 14-17 years) on community orders under the supervision of local youth offending teams (YOTs). Semi-structured interviews were conducted and data analysed using an inductive thematic analysis approach. Three main themes were identified: (i) people and places; (ii) growth; and (iii) managing difficult experiences. Findings suggest that young offenders are exposed to a wide range of challenging contextual factors including unpredictable or inadequate home environments, numerous transitions (between family members/foster placements and schools), limited engagement with educational settings and a lack of social support, supporting the findings of Paton et al. Findings also portrayed a sense of participants' 'psychological growth' with development along a trajectory from a young child 'acting out' in response to the environments in which they were living; through a more reflective stage, in which they were able to begin to consider the situations they found themselves in; before reaching a position in which they were able to look beyond their day-to-day circumstances with some hope that their lives could be different in the future. Furthermore, accounts revealed that these young people had a limited range of functional coping strategies and had largely negative experiences of services. Clinical implications and the need for further research developing professionals' understanding of the influence of early experiences on young offenders' behaviour are discussed.

Abnormal pigmentation within cutaneous scars: A complication of wound healing.

Abnormally pigmented scars are an undesirable consequence of cutaneous wound healing and are a complication every single individual worldwide is at risk of. They present a challenge for clinicians, as there are currently no definitive treatment options available, and render scars much more noticeable making them highly distressing for patients. Despite extensive research into both wound healing and the pigment cell, there remains a scarcity of knowledge surrounding the repigmentation of cutaneous scars. Pigment production is complex and under the control of many extrinsic and intrinsic factors and patterns of scar repigmentation are unpredictable. This article gives an overview of human skin pigmentation, repigmentation following wounding and current treatment options.